prescribing algorithms and pharmacotherapy troubleshooting ... · •cough develops pharmacological...

BASED ON ENHANCING KNOWLEDGE FOR INTERPROFESSIONAL CARE IN HEART FAILURE (EKWIP-HF) INTERVENTION (HECKMAN ET AL, 2017).

©2019, GEORGE A. HECKMAN, LORA BRUYN-MARTIN , SCHLEGEL-UW RESEARCH INSTITUTE FOR AGING, AND SCHLEGEL VILLAGES INC.

ALL RIGHTS RESERVED. PERMISSION TO REPRINT IN ITS ENTIRETY FOR NON-COMMERCIAL USE ONLY.

Prescribing Algorithms and Pharmacotherapy

Troubleshooting Guides

CONTRAINDICATIONS PRESENT?• Bilateral Renal Artery Stenosis

• Sever Aortic Stenosis• Angioedema/Allergy

ARE THE FOLLOWING SATISFIED?• Creatine Clearance > 30ml/min

• Potassium < 5.5 mmol/L• No symptomatic hypotension

CHECK-IN 7-14 DAYS• Creatine <30% increase• Potassium <5.5 mmol/L

• No symptomatic hypotension

If not at target increase dose in 2-4

weeksPrescribe ACEi

NO

YES

YES

1. Any reversible cause(s)? (See troubleshooting)2. If no reversible causes, reduce ACEi dose by 50%3. If no reversible causes on lowest ACEi dose or no

ACEi, then do not prescribe the ACEi

NO

NO RECHECK

For further details, please visit the Heart Failure Guidelines website: https://www.ccs.ca/en/guidelines/guidelines-library

DO NOT PRESCRIBE

YES

Using ACE Inhibitors (ACEi) for Heart Failure

Drug Starting DoseTitration

incrementIdeal Target Dose

Ramipril 1.25-2.5 mg od 2.5 mg 10 mg od or 5 mg bid

Lisinopril 2.5-5 mg od 5 mg od 30 mg od

Perindopril 2 mg od 2 mg 8 mg od

Enalapril 2.5-5 mg bid 5 mg od-bid 10 mg bid

CAUTIONif patient on

K+ supplements and/or ARB and/or

Spironolactone

https://www.ccs.ca/en/guidelines/guidelines-library








weeksPrescribe ARB

NO

YES

1. Any reversible cause(s)? (See troubleshooting)2. If no reversible causes, reduce ARB dose by 50%3. If no reversible causes on lowest ARB dose or no

ARB, then do not prescribe the ARB

NO


DO NOT PRESCRIBE

YES

Using Angiotensin Receptor Blockers (ARB) for Heart Failure

DrugStarting

DoseTitration

incrementIdeal Target

Dose

Candesartan 4 mg od 4-8 mg 32 mg od

Valsartan 40 mg od 40-80 mg 160 mg bid

CAUTIONif patient on

K+ supplements and/or ACEi and/or

Spironolactone

NO RECHECK

YES




ARE THE FOLLOWING SATISFIED?• No concurrent use of ACEi or ARB• Creatine Clearance > 30ml/min





weeksPrescribe S/V

NO

YES

YES

1. If on ACEi, discontinue ACEi for > 36 hours2. If on ARB, discontinue ARB3. Any reversible cause(s)? (See troubleshooting)4. If no reversible causes, reduce S/V dose by 50%5. If no reversible causes on lowest S/V dose or no S/V, then do

not prescribe the S/V

NO

NO RECHECK


DO NOT PRESCRIBE

YES

Using Sacubitril/ Valsartan (S/V) in Heart Failure


incrementIdeal Target

Dose

Sacubitril/Valsartan

24.3 mg/25.7 mg bid

48.6 mg/ 51.4 mg bid

97.3mg/ 102.8mg bid

CAUTION-stop previous

ACEi or ARB for >36 hours

-if patient on K+ supplements and/or

Spironolactone


CONTRAINDICATIONS PRESENT?• Symptomatic bradycardia• Severe reversible airway

obstruction• Allergy

ARE THE FOLLOWING SATISFIED?• No symptomatic hypotension

• SBP > 90mmHg and / or HR > 60/min• No current pulmonary congestion

Are the following ABSENT?• increased heart failure symptoms • fluid retention, weight gain (>2kg)

• Symptomatic hypotension or bradycardia (HR > 60/min)

If not at target then increase dose by 25-50% in 2-4 weeks

Prescribe ßB

NO

YES

YES

1. Any reversible cause(s)? (see troubleshooting)2. If no reversible cause, reduce βB dose by 50%3. If no reversible cause on lowest βB dose or no βB, then do not

prescribe the βB

NO

NO RECHECK


DO NOT PRESCRIBE

YES

Using Beta Blockers (ßB) for Heart Failure


incrementIdeal Target Dose

Bisoprolol 1.25-2.5 mg od 2.5 mg 10 mg od

Carvedilol 3.125 mg bid 6.25-12.5 mg 25-50 mg bid

Metoprolol* 12.5-25 mg bid 12.5-25 mg 75-100 mg bid*Metoprolol tartrate, available in Canada, has not been validated for HF. Consider switching to bisoprolol.

*Switching from Metoprolol to Bisoprolol

Metoprolol 25 mg bid ≈ 2.5 mg od

Metoprolol 50 mg bid ≈ 5 mg od

Metoprolol 75 mg bid ≈ 7.5 mg od

Metoprolol 100 mg bid ≈ 10 mg od


ARE INDICATIONS PRESENT?• Optimal ACEi/ARB and ßB

• Persistent dyspnea with even mild exertion and LVEF <35%• Recent hospitalization and persistent dyspnea with moderate

exertion and either LVEF ≤30% or LVEF ≥35% and QRS duration >130ms• No intolerance


• Serum K+ < 5.2 mmol/L• Have potassium supplements and other potassium-sparing diuretics been stopped?



If not at target increase dose in

2-4 weeksPrescribe AA

YES

YES

YES

1. Any reversible cause(s)? (See troubleshooting)2. If no reversible causes, reduce AA dose by 50% if

already prescribed, or stop/do not prescribe

NO

NO RECHECK


DO NOT PRESCRIBE

NO

Using Aldosterone Antagonists (AA) for Heart Failure

Drug Starting Dose Target Dose

Spironolactone 12.5 mg od 50 mg od

Eplerenone 25 mg q 2 days 50 mg od

CAUTIONDiabetics have an increased risk of

hyperkalemia and worsening renal

function


ARE INDICATIONS PRESENT?• Optimal ACEi/ARB, ßB and AA

• LVEF <35%• Resting Heart Rate >70, sinus rhythm• Not taking verapamil or diltiazem

• Normal QT• No intolerance

ARE THE FOLLOWING PRESENT?• Symptomatic bradycardia

• Prolonged QT

CHECK RESTING HEART RATE WITHIN 7 DAYS AND MONTHLY THEREAFTER

• No symptomatic bradycardia or hypotension

If not at target increase dose in

2-4 weeksPrescribe Ivabradine (see table)

YES

YES

YES

1. Any reversible cause(s)? (See troubleshooting)2. If no reversible causes, reduce Ivabradine dose by

50% if already prescribed, or stop/do not prescribe

NO

NO RECHECK


DO NOT PRESCRIBE

NO

Using Ivabradine for Heart Failure

Drug Starting Dose Target Dose

Ivabradine 2.5 mg po bid 7.5 mg po bid


ARE INDICATIONS

PRESENT?• Optimal

ACEi/ARB, ßBand/or Aldosterone Antagonist

• Persistent dyspnea with minimal exertion

• Left ventricular ejection fraction <45%

• No intolerance

• Check digoxin level, electrolytes and creatinine

• Consider holding digoxin

• Consider starting dose based on adjacent table

• Cut-dose in half if on Amiodarone, Clarithromycin or Verapamil

YES

PRACTICE TIPS• Digoxin levels should be checked 8-12 hours

after last dose• Target level is 1ng/ml or 1.4 mmol/L• Symptoms of toxicity may be non-specific

and include anorexia, nausea, depression, anxiety or delirium

• No need for routine monitoring: check levels when symptoms present


OPTIMIZE OTHER DRUGS

FIRST

NO

Using Digoxin for Heart Failure Creatinine clearance (mL/min/1.73m2)

Lean Body Weight (kg)40 50 60 70 80 90 100

0102030405060708090

100

Monitor for digoxin toxicity if creatinine rises

(e.g., dehydrating illness)

Check Potassium given increase toxicity with hypokalemia

If K+ <3.5 mmol/L consider

potassium supplement or reduce digoxin

dosage and repeat lab work

31.25 mcg62.5 mcg

125.0 mcg187.5 mcg

Misiaszek et al, Can J Card, 2005

CAUTIONS


Issue• Resident

becomes dizzy

Pharmacological triggering event↑ Dose of ACEi↑ Dose of ARB↑ Dose of S/V↑ Dose of ß-BlockerAND/OR↑ Dose of Ivabradine

Pharmacotherapy Troubleshooting:

Possible Causes• Hypovolemia from inadequate fluid intake and/or excessive diuresis• Initial diuresis related to Sacubitril/Valsartan initiation• Concurrent use of non-first line cardiovascular medication (nitrates, vasodilator,

calcium-channel blocker)• Orthostatic hypotension related to psychotropic or anticholinergic drug (e.g.,

tricyclic, dopaminergic)• If bradycardia < 50, consider other rate/ rhythm altering drugs such as amiodarone

or digoxin, or heart block

Possible Solutions• Reduce diuretic and

monitor resident• Reduce dose or

eliminate potentially offending drug

• If heart block present, avoid ß-Blocker / Ivabradine and/or consider cardiology referral

Reassess Resident in 1 week

The resident is dizzy when ACEi, ARB, S/V, ß-Blocker or Ivabradine dose is increased

Issue• Creatinine rises

Pharmacological triggering event↑ Dose of ACEi↑ Dose of ARBAND/OR↑ Dose of S/V


Possible Causes• Hypovolemia from inadequate fluid intake and/or excessive diuresis• Initial diuresis related to Sacubitril/Valsartan initiation• Normal response to ACEi / ARB if increase is no greater than 30% from baseline• Concurrent use of Non-Steroidal Anti-Inflammatory Drug (NSAID)

Possible Solutions• Reduce diuretic and

monitor resident• Reduce dose or

eliminate potentially offending drug


The creatinine rises after starting or increase ACEi, ARB or S/V dose

Issue• Creatinine

rises

Pharmacological triggering event↑ Dose of ACEi↑ Dose of ARB↑ Dose of S/VAND/OR↑ Dose of

spironolactone


Possible Causes• Worsening renal failure, especially among diabetic residents• Concurrent use of Non-Steroidal Anti-Inflammatory Drug (NSAID)• Resident prescribed potassium supplements

Possible Solutions• Reduce dose or eliminate potentially

offending drug• If no reversible cause found, and

resident is prescribed both an ACEI / ARB and an aldosterone antagonist, the preponderance of evidence suggests that aldosterone antagonist be discontinued first


Hyperkalemia occurs when the ACEi, ARB, S/V, or spironolactone is increased

Issue• Cough

develops

Pharmacological trigger• Use of ACEi


Possible Causes• The resident has developed worsening pulmonary edema• The resident has developed an infectious process or has a post-

viral cough• The resident has developed an ACE-Inhibitor cough

Possible Solutions• Assess the resident for possible

pulmonary edema and treat with temporary increase in diuretics, the reassess

• If cough is TRULY intolerable and no obvious cause is found, stop the ACEi and consider and ARB. If cough persists with ARB, consider combination therapy with nitrates and hydralazine


The resident develops a cough while on an ACEi

prescribing algorithms and pharmacotherapy troubleshooting ... · •cough develops pharmacological...

Documents